Table 1.

The primary incident types from the included reports and the harm outcomes from the a priori coding using the PISA classification.

Incident type	Severe harm	Death	Unclear (severe harm or death)	Total
Treatment or procedure	23	43	41	107
Insufficient treatment/care/monitoring	13	28	16	57
Treatment not given in a timely fashion	4	7	9	20
Error in conducting procedure	3	1	3	7
Complication		1	5	6
No treatment/care give	2	4	6	12
Other	1	2	2	5
Diagnosis and assessment	32	35	38	105
Diagnostic error	30	25	24	79
Insufficient assessment of patient	2	4	7	13
Errors in discharge, including premature discharge		3	3	6
Delayed assessment		3	4	7
Medication	19	14	28	61
Clinical treatment decision	6	5	10	21
Prescribing	6	3	2	11
Drug omission		1	7	8
Administration	1	1	5	7
Timeliness of medication	3	2	2	7
Other (dispensing, adverse events, overdose)	3	2	2	7
Referral	9	10	25	44
Staff errors during referral of a patient	4	7	14	25
Errors in transfer (wrong location or transfer delayed)	4	3	10	17
Other	1		1	2
Investigation	4	9	13	26
Laboratory tests and results	3	6	3	12
Imaging investigations	1	2	10	13
Other investigations		1		1
Equipment	1	2	15	18
Failure of equipment			6	6
Insufficient supply of equipment		1	6	7
Other	1	1	3	5
Administration	1		5	6
Communication	2	2	3	7
Other		1	2	3

The harm severity of reports was coded according to the harm severity levels from the WHO International Classification for Patient safety: ²⁰ • No harm: Patient has no symptoms and no further treatment is necessary • Low harm: Mild symptoms experienced that are short term. None or little treatment is necessary. • Moderate harm: Patient experiences symptoms, further interventions or a longer admission are needed, and the resulting harm or loss of function is either permanent or long standing • Severe harm: Major or life-saving treatment/intervention is required which leads to a reduced life expectancy or permanent or long-term serious loss of function or harm • Death: The incident caused the death of the patient